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Balance and walking after three different models of stroke rehabilitation: early supported discharge in a day unit or at home, and traditional treatment (control)

Objective To compare the effects on balance and walking of three models of stroke rehabilitation: early supported discharge with rehabilitation in a day unit or at home, and traditional uncoordinated treatment (control). Design Group comparison study within a randomised controlled trial. Setting Hospital stroke unit and primary healthcare. Participants Inclusion criteria: a score of 2–26 on National Institutes of Health Stroke Scale, assessed with Postural Assessment Scale for Stroke (PASS), and discharge directly home from the hospital stroke unit. Interventions Two intervention groups were given early supported discharge with treatment in either a day unit or the patients own home. The controls were offered traditional, uncoordinated treatment. Outcome measures Primary: PASS. Secondary: Trunk Impairment Scale—modified Norwegian version; timed Up-and-Go; 5 m timed walk; self-reports on problems with walking, balance, ADL, physical activity, pain and tiredness. The patients were tested before randomisation and 3 months after inclusion. Results From a total of 306 randomised patients, 167 were tested with PASS at baseline and discharged directly home. 105 were retested at 3 months: mean age 69 years, 63 men, 27 patients in day unit rehabilitation, 43 in home rehabilitation and 35 in a control group. There were no group differences, either at baseline for demographic and test data or for length of stroke unit stay. At 3 months, there was no group difference in change on PASS (p>0.05). Some secondary measures tended to show better outcome for the intervention groups, that is, trunk control, median (95% CI): day unit, 2 (0.28 to 2.31); home rehabilitation, 4 (1.80 to 3.78); control, 1 (0.56 to 2.53), p=0.044; and for self-report on walking, p=0.021 and ADL, p=0.016. Conclusions There was no difference in change between the groups for postural balance, but the secondary outcomes indicated that improvement of trunk control and walking was better in the intervention groups than in the control group. Trial registration This study is part of the Early Supported Discharge after Stroke in Bergen, ClinicalTrials.gov (NCT00771771).

Airway obstruction, dynamic hyperinflation, and breathing pattern during incremental exercise in COPD patients

Ventilatory capacity is reduced in chronic obstructive pulmonary disease (COPD) patients. Tidal volume (VT) is lower and breathing frequency higher at a given ventilation (VE) compared to healthy subjects. We examined whether airflow limitation and dynamic hyperinflation in COPD patients were related to breathing pattern. An incremental treadmill exercise test was performed in 63 COPD patients (35 men), aged 65 years (48–79 years) with a mean forced expiratory volume in 1 sec (FEV1) of 48% of predicted (SD = 15%). Data were averaged over 20‐sec intervals. The relationship between VE and VT was described by the quadratic equation VT = a + bVE + cVE2 for each subject. The relationships between the curve parameters b and c, and spirometric variables and dynamic hyperinflation measured as the difference in inspiratory capacity from start to end of exercise, were analyzed by multivariate linear regression. The relationship between VE and VT could be described by a quadratic model in 59 patients with median R2 of 0.90 (0.40–0.98). The linear coefficient (b) was negatively (P = 0.001) and the quadratic coefficient (c) positively (P < 0.001) related to FEV1. Forced vital capacity, gender, height, weight, age, inspiratory reserve volume, and dynamic hyperinflation were not associated with the curve parameters after adjusting for FEV1. We concluded that a quadratic model could satisfactorily describe the relationship between VE and VT in most COPD patients. The curve parameters were related to FEV1. With a lower FEV1, maximal VT was lower and achieved at a lower VE. Dynamic hyperinflation was not related to breathing pattern when adjusting for FEV1.

Impact of a Multifaceted and Clinically Integrated Training Program in Evidence-Based Practice on Knowledge, Skills, Beliefs and Behaviour among Clinical Instructors in Physiotherapy: A Non-Randomized Controlled Study.

Background and Purpose Physiotherapists practicing at clinical placement sites assigned the role as clinical instructors (CIs), are responsible for supervising physiotherapy students. For CIs to role model evidence-based practice (EBP) they need EBP competence. The aim of this study was to assess the short and long term impact of a six-month multifaceted and clinically integrated training program in EBP on the knowledge, skills, beliefs and behaviour of CIs supervising physiotherapy students. Methods We invited 37 CIs to participate in this non-randomized controlled study. Three self-administered questionnaires were used pre- and post-intervention, and at six-month follow-up: 1) The Adapted Fresno test (AFT), 2) the EBP Belief Scale and 3) the EBP Implementation Scale. The analysis approach was linear regression modeling using Generalized Estimating Equations. Results In total, 29 CIs agreed to participate in the study: 14 were invited to participate in the intervention group and 15 were invited to participate in the control group. One in the intervention group and five in the control group were lost to follow-up. At follow-up, the group difference was statistically significant for the AFT (mean difference = 37, 95% CI (15.9 -58.1), p<0.001) and the EBP Beliefs scale (mean difference = 8.1, 95% CI (3.1 -13.2), p = 0.002), but not for the EBP Implementation scale (mean difference = 1.8. 95% CI (-4.5-8.1), p = 0.574). Comparing measurements over time, we found a statistically significant increase in mean scores related to all outcome measures for the intervention group only. Conclusions A multifaceted and clinically integrated training program in EBP was successful in improving EBP knowledge, skills and beliefs among CIs. Future studies need to ensure long-term EBP behaviour change, in addition to assessing CIs’ abilities to apply EBP knowledge and skills when supervising students.

Peak oxygen uptake and breathing pattern in COPD patients – A four year longitudinal study

Background: Knowledge of longitudinal changes in exercise capacity and breathing pattern in COPD is scarce. Aims: To examine longitudinal changes in peak oxygen uptake (VO2peak) and breathing pattern in COPD patients and to examine potential predictor variables. We hypothesized decline in exercise capacity and a shallower breathing pattern with a lower maximaltidal volume (VT). Methods: The study included 63 COPD patients, aged 44-75 yrs and mean FEV1 at baseline of 51% of predicted (SD=14). Two incremental treadmill tests were performed 4.5 yrs apart. The relationship between changes in VO2peak and explanatory variables, including dynamic lung volumes and inspiratory capacity (IC), were analysed by multivariate regression analyses. The breathing pattern in terms of the relationship between minute ventilation (VE) and VT was described by a quadratic equation, VT=a+bVE+cVE2. Regression analyses were done for each subject at both tests. The mean change in the curve parameters (test 2 minus test 1) were analysed by bi- and multivariate linear regression analyses with age, sex and changes in: weight, FEV1 and resting IC as explanatory variables. Results: A significant reduction in VO2peak (p<0.001) was related to decreasing resting IC (Standardised beta (St.B)=0.492, p=0.002), reduction in FEV1 (St.B=0.251, p=0.031) and persistentsmoking (St.B=−0.240, p=0.021). The breathing pattern changed towards a lower VT at a given VE and was related to reduction in FEV1 (p<0.017). Conclusion: Increasing static hyperinflation and airway obstruction were related to reduced exercise capacity. The breathing pattern changed towards shallower breathing and was related to increasing airway obstruction.